Using simulation to isolate physician variation in intensive care unit admission decision making for critically ill elders with end-stage cancer: a pilot feasibility study.
OBJECTIVE
To determine the feasibility of high-fidelity simulation for studying variation in intensive care unit admission decision making for critically ill elders with end-stage cancer.


METHODS
Mixed qualitative and quantitative analysis of physician subjects participating in a simulation scenario using hospital set, actors, medical chart, and vital signs tracings. The simulation depicted a 78-yr-old man with metastatic gastric cancer, life-threatening hypoxia most likely attributable to cancer progression, and stable preferences to avoid intensive care unit admission and intubation. Two independent raters assessed the simulations and subjects completed a postsimulation web-based survey and debriefing interview.


METHODS
Peter M. Winter Institute for Simulation Education and Research at the University of Pittsburgh.


METHODS
Twenty-seven hospital-based attending physicians, including 6 emergency physicians, 13 hospitalists, and 8 intensivists.


RESULTS
Outcomes included qualitative report of clinical verisimilitude during the debriefing interview, survey-reported diagnosis and prognosis, and observed treatment decisions. Independent variables included physician demographics, risk attitude, and reactions to uncertainty. All (100%) reported that the case and simulation were highly realistic, and their diagnostic and prognostic assessments were consistent with our intent. Eight physicians (29.6%) admitted the patient to the intensive care unit. Among the eight physicians who admitted the patient to the intensive care unit, three (37%) initiated palliation, two (25%) documented the patient's code status (do not intubate/do not resuscitate), and one intubated the patient. Among the 19 physicians who did not admit the patient to the intensive care unit, 13 (68%) initiated palliation and 5 (42%) documented code status. Intensivists and emergency physicians (p = 0.048) were more likely to admit the patient to the intensive care unit. Years since medical school graduation were inversely associated with the initiation of palliative care (p = 0.043).


CONCLUSIONS
Simulation can reproduce the decision context of intensive care unit triage for a critically ill patient with terminal illness. When faced with an identical patient, hospital-based physicians from the same institution vary significantly in their treatment decisions.
Barnato
Amber E
AE
University of Pittsburgh, Pittsburgh, PA, USA. aeb2@pitt.edu
Hsu
Heather E
HE
Bryce
Cindy L
CL
Lave
Judith R
JR
Emlet
Lillian L
LL
Angus
Derek C
DC
Arnold
Robert M
RM
D000328:Adult; D016223:Advance Directives; D000368:Aged; D001291:Attitude of Health Personnel; D016638:Critical Illness; D003710:Demography; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000628:therapy*; D010166:Palliative Care; D010343:Patient Admission; D016544:Patient Simulation; D010865:Pilot Projects; D010818:Practice Patterns, Physicians'; D018570:Risk Assessment; D013727:Terminal Care; D013997:Time Factors